Healthcare Provider Details

I. General information

NPI: 1194110189
Provider Name (Legal Business Name): KATHERINE MACCALLUM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 09/21/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 DUDLEY ST STE 470
PROVIDENCE RI
02905-3248
US

IV. Provider business mailing address

2 DUDLEY ST STE 470
PROVIDENCE RI
02905-3248
US

V. Phone/Fax

Practice location:
  • Phone: 401-553-8325
  • Fax: 401-868-2336
Mailing address:
  • Phone: 401-553-8325
  • Fax: 401-868-2336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number293441
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD18473
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: